UniCare Limitations & Exclusions
Not all UniCare individual health policies contain the same exclusions, and these exclusions can change as UniCare updates their contracts. The following exclusions
should be interpreted as providing only a general representation of what UniCare does not cover under its individual policies for Illinois and Indiana residents:
- Services for any condition for which benefits are excluded by a waiver
- Any amounts in excess of maximum amounts of covered expenses
- Services not specifically listed in the plan as covered services
- Services or supplies that are not medically necessary
- Services or supplies that UniCare considers to be experimental or investigative procedures
- Services received before the effective date of coverage or during an inpatient stay that began before the effective date.
- Services received after coverage ends
- Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage
- Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any Workers’ Compensation, employer’s liability
law or occupational disease law, even if you do not claim those benefits
- Any intentionally, self-inflicted injury or illness
- Conditions caused by (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from
such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e)
services received as a direct result of an insured person’s commission of, or attempt to commit a felony; or as a direct result of the insured person being engaged in an illegal occupation;
( f ) an insured person, being under the influence of illegal narcotics or non-prescribed controlled substances unless administered on the advice of a physician
- Any services provided by a local, state or federal government agency except when payment under this plan is expressly required by federal or state law
- If you are eligible for Medicare, any services covered by Medicare under Part A or B are excluded from consideration of payment regardless of actual enrollment in
Medicare or payment by Medicare for those services
- Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration hospitals and military
treatment facilities will be considered for payment according to current law
- Professional services received or supplies purchased from yourself, a person who lives in the insured person’s home or who is related to the insured person by blood,
marriage or adoption, or the insured person’s employer
- Inpatient or outpatient services of a private duty nurse
- Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures; services provided
by a rest home, a home for the aged, a nursing home or any similar facility service
- Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis
- Treatment of drug or other substance addiction or abuse, except for treatment of alcoholism as specifically provided for in the
plan
- Dental services
- Orthodontic services
- Dental implants or any associated procedure
- Hearing aids
- Routine hearing tests except as provided under Well Baby and Well Child Care.
- Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine
eye exams, and routine eye refractions, except as specifically stated in the plan
- An eye surgery solely for the purpose of correcting refractive defects of the eye
- Outpatient speech therapy
- Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as
specifically stated in the plan. This includes, but is not limited to items dispensed by a physician
- Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not
apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or to medically necessary
reconstructive surgery performed to restore symmetry incident to a mastectomy
- Procedures or treatments to change characteristics of the body to those of the
opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change
- Treatment of sexual dysfunction, impotence and/or inadequacy
- All services related to the evaluation or treatment of fertility and/or infertility, including, but not limited to all tests, consultations,
examinations, medications, invasive, medical, laboratory or surgical procedures, including sterilization reversals and in vitro fertilization
- Cryopreservation of sperm or eggs
- All nonprescription contraceptive drugs, devices, and/or supplies that are available over-the-counter or without a
prescription and non-FDA approved prescription contraceptive drugs, devices, and/or supplies
- Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics
- Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment
- Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority
- Charges by a provider for telephone consultations
- Items which are furnished primarily for your personal comfort or
convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs, etc.)
- Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare
- Nutritional counseling or food supplements
- Any services received on or within twelve months after the effective date of coverage if they are related to a pre-existing condition
- Incidental supplies used by a provider in the administration of infusion therapy
- Foreign country provider charges except as specifically stated in the plan
- Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented
growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the
insured person’s condition.
- Routine foot care
- Charges for which we are unable to determine our liability because you or an insured person failed, within 60 days, or as soon as reasonably possible to (a) authorize us to receive all the medical records and information we requested, or (b) provide us with
information we requested regarding the circumstances of the claim or other insurance coverage
- Charges for animal to human organ transplants
- Charges for normal pregnancy or maternity care, including normal delivery, elective abortions and elective non-emergency cesarean sections, as long as the service is not
related to complications of pregnancy
- Drugs and medications not requiring a prescription, except insulin
- Drugs and medications to induce nonspontaneous abortions
- Dietary supplements, cosmetics, health or beauty aids
- Any vitamin, mineral, herb or botanical product which does not have an FDA (Food and Drug Administration) approved indication to treat, diagnose or cure a medical condition even if it is thought
to have health benefits
- Any expense incurred in excess of the UniCare negotiated rate
- Any drug labeled “Caution, limited by federal law to investigational use” or non-FDA approved investigational drugs. Any drug or medication prescribed for experimental
indications
- Drugs used for cosmetic purposes
- Drugs used for the primary purpose of treating infertility or promoting fertility
- Anorexiants or drugs associated with weight loss
- Drugs obtained outside the United States
- Drugs for treatment of a condition, illness, or injury for which benefits are excluded or limited by a waiver, pre-existing condition, or other contract limitation
- Prescription drugs with a nonprescription (over-the-counter) chemical and dose equivalent
- Lost or stolen prescriptions
- All contraceptive services and supplies including, but not limited to : All tests, consultations, examinations, evaluations, medications, medical,
laboratory, devices, prescription drugs, or surgical procedures
